STATE OF TENNESSEE
Managed Long Term
Services and Supports
November 18, 2015
• In 1994, Tennessee restructured its Medicaid program and became the
first state in the nation to enroll its entire Medicaid population into
managed care, as well as being the only state to offer Medicaid to all
uninsured and uninsurable citizens – regardless of income.
• This restructured and expanded Medicaid program was renamed
“TennCare”.
• At inception, the thought was the cost-savings from a managed care
model would allow the state to cover an expanded population
(individuals who would not qualify under traditional Medicaid eligibility
standards) and additional benefits.
• As a revolutionary model, this approach brought about some
challenges which prompted the program to change and evolve to
become the program it is today.
2
Carved In
At TennCare’s inception, there were 12 different
community service areas (CSAs) and a dozen health plans
- only two were statewide. TennCare did not restrict the
number of health plans; nor did it require a procurement
process for plan selection. Prior to TennCare, Tennessee
Medicaid was entirely fee-for-service.
• 12 Plans total – 8 HMOs; 4 PPOs
• Risk Model – All plans were “at-risk”
• Total Enrollment – 1.1 million
•
•
•
•
Physical
Dental
Pharmacy
Routine Mental
Health Services
Carved Out
• Long-Term Care
• Specialized
Mental Health
Services
TennCare outlined basic quality management
requirements in the contracts with the health
plans and contracted with an External Quality
Review Organization (EQRO) to review and
report on MCO quality. Out of necessity, the
EQRO’s primary focus was on getting health
plans to a point where they had appropriate
policies in place.
• Quality of encounter data – poor
• Network monitoring focused on Geoaccess
mapping of MCO reported primary care
providers
• Appeals were handled by MCOs
• TennCare Satisfaction Survey: 1994 – 61%
3
By 2003, TennCare required all health plans to be HMOs
and serve all areas within each Grand Region in which
they participate, resulting in three Service Areas (West,
Middle and East). At this time, health plans had begun to
experience problems, and some were at risk of becoming
insolvent which caused the state to bring them into an
Administrative Service Organization (ASO) arrangement.
Contributing factors included the impact of
lawsuits/consent decrees and a lack of experience and
capital on the part of some MCOs.
• 9 plans – all HMOs
• Risk Model – All plans were brought into an ASO
arrangement (no risk)
• Total Enrollment – 1.35 million
Carved In
• Physical
Carved Out
•
•
•
•
Behavioral Health
Dental
Pharmacy
Long-Term Care
By now the EQRO was able to focus on
adherence to policies. Encounter data quality
had improved. By the late 90’s, TennCare had
commissioned several studies on quality
including delivery of preventative services,
prenatal care and ER utilization. In addition,
an annual Women’s Health report was being
produced.
• Network requirements were expanded to
include specialty standards
• Management of appeals shifted to
TennCare
• TennCare Satisfaction Survey : 2003 – 83%
4
TennCare transitioned to three statewide MCOs and had
already limited the MCO network to 3 plans. LTSS for the
elderly and adults with physical disabilities has been fully
integrated into the managed care model. Integration of
physical health, behavioral health and LTSS services
promotes improved coordination of care for the “whole
person.” Further integration of LTSS services for individuals
with intellectual & developmental disabilities into managed
care has been designed and is scheduled to be implemented
in 2016. Payment & delivery system redesign is on track to
impact 80% of Tennesseans by 2020.
• 3 statewide plans – all HMOs
• Risk Model – At-risk
• Total Enrollment – 1.4 million
Carved
CarvedIn
In
• Physical
• Behavioral
Health
• Long-Term
Care (for E/D)
Carved
CarvedOut
Out
• Dental
• Pharmacy
• Long-Term
Care (for ID)*
*ECF CHOICES planned go-live 7/2016
Today, TennCare rates above the national
Medicaid average in many quality measures
and continues to demonstrate
improvement. With the integration of LTC
into the managed care model, efforts to
monitor quality of care in the elderly and
disabled population are a new focus of
attention.
We continue to enhance quality standards –
recently added contractual requirement for
all plans to utilize hybrid methodology in
HEDIS reporting in cases where either
hybrid or administrative is acceptable to
NCQA
TennCare Satisfaction Survey: 2015 – 95%
5
Millions
9.0%
10.00%
7.5%
8.00%
7.0%
6.00%
3.8%
4.00%
4.1%
3.2%
2.00%
0.00%
2012
TennCare
Millions
Projected Medical Inflation Trends
National Medicaid *
2013
Commercial Insurance**
*Source: OMB 2012; Kaiser 2013 **Source:
PricewaterhouseCoopers
Pharmacy
• Point of Sale Edits
• Preferred Drug
List/Drug
Rebates/Generics
• Prescription Limits
Medical
• Prior authorization
• Medical Home
• Network Consolidation
• Disease Management
• Case Management
Fraud and Abuse
• Narcotic Controls
• Pharmacy Lock-In
• Outlier Monitoring
6
2005
TennCare medical inflation trend has remained
well below trends for other Medicaid agencies
and Commercial plans for years.
For the past 10 years
we’ve consistently
remained
approximately 20% of
state appropriations.
2010*
State
TennCare
2015
12
8
6
4
* So as not to under-report
TennCare Appropriations,
2009, 2010 & 2011 were
increased to account for
ARRA. The increases for these
years were taken from the
2011 Governor's
Recommended Budget.
2
0
-2
ME
CA
MN
MO
AZ
VT
LA
OK
CO
SD
NM
FL
MS
MA
PA
CT
OR
VA
DE
MD
WI
US Avg.
ID
MT
TX
AR
OH
WA
IL
IA
AK
RI
WV
KY
NC
GA
IN
NE
AL
HI
UT
NV
WY
NJ
MI
KS
SC
NY
TN
NH
ND
Percentage Points
10
Percent point increase
from 2000 to 2013 in
Medicaid spending as part
of state budget (state
dollars).
http://www.pewtrusts.org/en/multimedia/data-visualizations/2014/fiscal-50#ind7
7
• In 2006, TennCare became the first state in the country to
require NCQA accreditation across 100% of its fully
Medicaid managed care network.
• NCQA is an independent, nonprofit organization that
assesses and scores managed care organization
performance in the areas of quality improvement,
utilization management, provider credentialing and
member rights and responsibilities.
• TennCare MCOs are also required to report the full set of
HEDIS measures. HEDIS is a set of standardized
performance measures that makes it possible to track
and compare MCO performance over time.
All Time
High – 95%
Out of 33 HEDIS measures tracked since 2007, 28
have shown improvement over time (85%).
These measures include access and availability,
prevention and screening, and effectiveness of
care.
47 measures have shown improvement from
2014-2015
UT surveys random sampling of TennCare households
for annual satisfaction report.
8
Rapidly Escalating Costs
Stable Cost Trends
Volatile Health Plans
Experienced, Well-Capitalized
Health Plans
Few Quality Measures / Data
Limitations
NCQA Accreditation & Full Set of
HEDIS Measures & CAHPS/
Improved Data Capabilities
Fragmented Long-Term Services
and Supports System
Integrated Long-Term Services
and Supports Home and
Community Based Options
9
22 States Had MLTSS Programs as of May 2015
WA
MN
MN
WI


KS
KS
CA
AZ
PA
PA
OH
IL
IL
NJ
RI
DE

VA
NC
TN
TN
NM
NM
MA
NY
MI
MI
SC
TX
TX
FL
FL
HI
MLTSS implemented 1989-2004
MLTSS implemented 2005- March 2015
©Truven Health Analytics Inc. All Rights Reserved.
10
Better Experience
Coordination of services; integration with
primary, acute, and behavioral
Better Outcomes
Health, function, quality of life
Flexibility
Ability to tailor unique services/supports
Predictable, Managed Costs
Budget stability and trend management
Alignment of financial incentives
Pay for quality and value
Expanded access to HCBS
The potential to provide services to more
people and for increased flexibility in
service provision—if done “right”
System Balancing
Increase use of community services and
decrease inappropriate use of institutional
services
Source: Truven Health--modified
11
• Fragmented—carved out of managed care program
• Limited options and choices
• Heavily institutional; dependent on new $ to expand HCBS
Nursing Facilities
99.26%
Nursing Facilities
90.68%
FY 1999
FY 2009
< 1%
HCBS
~ 10%
HCBS
HCBS
HCBS
9.32%
_________________________________________________________________________
.74%
• Reorganize – Decrease fragmentation and improve coordination of care.
• Refocus – Increase options for those who need LTSS and their families, expanding access
to HCBS so that more people can receive care in their homes and communities.
• Rebalance – Serve more people using existing LTSS funds, creating a more sustainable system.
• Extensive stakeholder engagement
• Comprehensive LTSS system reform legislation:
The Long-Term Care Community Choices Act of 2008
• Integrated TennCare nursing facility (NF) services and HCBS for
the elderly and adults with physical disabilities into the existing
managed care delivery system (roughly $1 billion)
• Blended capitation payment for all physical, behavioral and LTC
services; risk adjusted for non-LTC rate component based on
health plan risk assessment scores and for LTC component based
on service mix by setting (NF versus HCBS)
• MCOs at full risk for all services, including NF (not time-limited)
• Enrollment target for HCBS supports controlled growth while
developing sufficient community infrastructure to provide care
(persons transitioning from a NF and certain persons at risk
of NF placement are exempt)
13
• Cost and utilization managed via individual benefit limits, levels of
care (LOC), and individual cost neutrality cap
• MCOs provide comprehensive person-centered care coordination,
including social support needs (social determinants)
o Strengthened requirements and investments in health plan and
provider capacity for person-centered planning and support
delivery, employment and community integration
• Nursing facility diversion and transition programs, including
Money Follows the Person Rebalancing Demonstration
• Electronic Visit Verification system provides fiscal accountability,
immediate notification/resolution of potential gaps in care
o New technology engages paid caregivers as part of care team
(ongoing status updates) and gathers point-of-service member
satisfaction data)
• Consumer direction using an employer authority model allows
individuals to hire family and friends to provide HCBS
14
LTSS Enrollment before CHOICES
Program (March/August 2010)
LTSS Enrollment
as of August 1, 2015
HCBS
17%
HCBS
44%
NF
57%
NF
83%
Nursing Facility Enrollment
HCBS Enrollment
90%
90%
70%
70%
50%
50%
30%
30%
10%
10%
15
• Global budget approach:
16,000
13,409
HCBS Enrollment*
14,000
12,000
10,000
8,000
6,000
Expanded access to HCBS
subject to new appropriations
6,000
4,861
4,000
HCBS enrollment
without CHOICES
2,000
0
1,131
0
No state-wide HCBS
alternative to NFs
available before
2003.
CMS approves
HCBS waiver
and
enrollment
begins in 2004.
Slow growth in
HCBS –
enrollment
reaches 1,131
after two years.
HCBS enrollment
at CHOICES
implementation
* Excludes the PACE program which serves 325 people almost exclusively in
HCBS, and other limited waiver programs no longer in operation.
Well over twice as
many people who
qualify for nursing
facility care receive
cost-effective HCBS
without a program
expansion request;
additional cost of NF
services if HCBS not
available approx.
$250 million
(federal and state).
Limited LTC funding spent
based on needs and
preferences of those who
need care
More cost-effective HCBS
serves more people with
existing LTC funds
Critical as population ages
and demand for LTC
increases
HCBS waiting
list eliminated
in CHOICES
16
• Number of persons receiving HCBS in CHOICES increased by
nearly 170% since the program began (from 4,861 to 13,032, as
of 11/1/15)
• Number of persons receiving NF services in CHOICES has
declined by nearly 6,000 people (from 23,076 to 17,248, as of
11/1/15)
• Percentage of people coming into LTSS in a NF declined from
81.34% in the year immediately preceding CHOICES
implementation to 47.93% as of 6/30/14, with more than 50% of
people choosing HCBS upon enrollment in CHOICES for each of
the past two years reported in the CHOICES baseline data
• Average length of stay in a NF has declined from 285 days to 250
days
17
• More than 2,500 individuals transitioned from NFs to HCBS as of
6/30/14, an average of 646 individuals per year, compared to 129
people in the baseline year immediately preceding CHOICES
• More than 10% of CHOICES members (1,475) receiving HCBS
actively participating in Consumer Direction for some or all
services; more than 300 additional persons in referral process
▫ Consumer direction options not available for this population prior to
CHOICES implementation
▫ Ability to self-direct health care tasks
• MCOs consistently monitoring and address potential gaps in
care—for example, during the 12 month period beginning
October 1, 2014 through September 30, 2015:
▫ More than 95% of all scheduled in-home care visits were completed,
except for reasons initiated by the member.
▫ More than 99.5% of home care visits provided were on time, except
for reasons initiated by the member.
18
• Managed care is not “the way” to improve quality
and achieve savings.
• There is no one “right way” to implement MLTSS.
o Every state is different.
o Every program is different.
o Every population is different.
“If you’ve seen one MLTSS program,
you’ve seen one MLTSS program.”
o Have to figure it out together
 What works for the people you want to serve
(right services)
 In your state (right place)
 Now (right time)
19
• Active and ongoing stakeholder engagement is
essential to designing and implementing MLTSS.
o Comprehensive reform legislation: The Long Term Care
Community Choices Act of 2008
o Ongoing stakeholder meetings
 Provider groups
 Advocacy groups
o Mechanisms for input directly from consumers/family members
 CHOICES Advisory Groups
 Regional community forums/online surveys
o Stakeholder engagement in key program design elements
o Stakeholder engagement in oversight and monitoring processes
20
• Quality and cost are inextricably linked.
o Coordination of care improves quality of care; higher
quality care is also more cost-effective.
o Integration of services that allows for coordination
across the continuum has the highest potential to
achieve the best quality of care and outcomes,
especially for populations with complex support
needs.
 Greatest challenge = greatest opportunity
21
• Managed care is a set of tools and principles that can
help improve coordination, quality and cost-effectiveness
of care for the most complex populations. It is up to us
to implement those tools in the right way to achieve the
desired objectives and preserve core system values.
o Detailed program design and contract requirements, with
aligned financial incentives and enforcement mechanisms, and
appropriate reporting and monitoring processes are necessary
to assure quality and compliance.
 Trust but verify.
o One of the greatest opportunities in managed care is the
opportunity to align financial incentives to achieve the outcomes
that are important to you and to the people you serve.
 MCOs will do what you pay them to do, require them to do,
22
and hold them accountable for doing.
• Working with MCOs is an accountable partnership.
o Choosing the right partners is important. Procurement
strategies should focus not just on managed care
experience/expertise, but on experience with LTSS and with
integrated approaches to planning and service delivery.
 Do they really understand person-centered planning?
 Do they understand employment and integration and know
to plan and support it?
 Be sure your partners understand your vision, share your
values, and have the ability and commitment to do it right.
o You will have to invest in helping your MCOs understand your
expectations and implement the program in a manner that’s
consistent with your expectations.
23
• Implementing managed care “well” and achieving
program objectives requires a significant investment
in the State’s capacity to “manage” managed care.
o It takes different kinds of skills and expertise to “manage”
managed care well.
o State leadership must be integrally involved in day-to-day
program management and oversight and willing to hold MCOs
accountable.
24
• It takes time to design and implement managed
care.
o Moving too quickly will undermine the success of your
program.
o A comprehensive readiness review strategy is critical.
Show and tell.




Review of key desk deliverables
Onsite review of critical processes and operating functions
Systems testing
Key milestone deliverables
o Be careful not to confuse the success of the model with the
success of the implementation.
25
• It also takes time to achieve savings.
o The initial focus must be on ensuring that:
Members get services
and
providers get paid.
o Assuming savings too quickly can shift the focus away
from these non-negotiables and undermine quality
and cost efficiency goals.
26
•
•
•
•
•
•
•
•
What do you want to achieve (change)?
What do you want to preserve (sustain)?
What is the best way to accomplish both of those things?
What will it take to get there?
How long will it take to get there?
Who do you need to be sure is along for the ride?
Are you ready and willing to make those investments?
Who can help?
27
THANK YOU
Patti Killingsworth
Assistant
Commissioner/Chief of LTSS
Patti.Killingsworth@tn.gov
TennCare MCO contract available at:
http://www.tn.gov/assets/entities/te
nncare/attachments/MCOStatewide
Contract.pdf